What are the recommended management strategies for a patient with symptomatic hypercalcaemia?

Management strategies for a patient presenting with symptomatic hypercalcaemia include:

• For severe hypercalcaemia (calcium >3.5 mmol/L) or severe symptoms, offer emergency hospital admission for specialist assessment and management, including intravenous fluids and intravenous bisphosphonate therapy, tailored to clinical judgement and patient wishes.
• For moderate hypercalcaemia (calcium 3–3.5 mmol/L) or symptoms, arrange urgent assessment in hospital or hospice settings, considering patient preferences and liaising with oncologists or palliative care specialists.
• For mild hypercalcaemia (<3 mmol/L) with minimal or no symptoms, review and stop medications that may exacerbate hypercalcaemia (e.g., thiazide diuretics, lithium, calcium or vitamin D supplements) where appropriate, and arrange monitoring and follow-up in primary care.
• Advise maintaining adequate oral hydration to help manage calcium levels.
• Specialist management may include intravenous rehydration, intravenous bisphosphonates or denosumab to reduce bone resorption, calcitonin, corticosteroids if hypercalcaemia is calcitriol-mediated, correction of vitamin D deficiency, treatment of underlying malignancy, and surgical removal of abnormal parathyroid tissue if indicated.
• Referral to palliative care specialists should be considered for additional support, especially in malignancy-related hypercalcaemia or end-of-life care.

These strategies should be individualized based on the severity of hypercalcaemia, symptoms, underlying cause, clinical context, and patient preferences.

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